# Acute Hypoxic/Hypercarbic *** Respiratory Failure 2/2 ***
-- ABCs: *** pulse ox, ABG - does the patient need to go to the ICU for monitoring or be intubated in the near-term
-- Chart Check: home O2 use, previous intubations, underlying pulm disease, right heart function (previous echo), meds,
-- HPI Intake: ***
-- Can't Miss: *** PE and right heart strain (may decompensate if intubated), ARDS (avoid barotrauma), tension PTX, opioid overdose, anaphylaxis, stroke, carbon-monoxide toxicity
-- Admission Orders: CBC, BMP, ABG, EKG, continuous pulse ox, tele; consider trop, BNP, dimer, need for CT chest
-- Initial Treatment to Consider: treat underlying etiology (diuresis, abx, steroids, vasodilators), consider need for HFNC
-- History: ***
-- Clinical: *** SOB, cough, chest pain, somnolence, anxiety, headache,
-- Exam: *** WOB (nasal flare, pursed lips, accessory muscle use, retraction, tripoding), secretions, rhonchi/wheezing, crackles, AMS
-- Data: *** SpO2, ABG, lactate, CXR, cultures
-- Etiology/DDx: Hypoxemia: edema, PNA, ARDS, PTX, PAH, PE; Hypercarbia: COPD, asthma bronchiectasis/CF, angioedema, OSA, laryngospasm, CNS depression (opioids, TBI, cerebral hernitation), resp muscle weakness; Tachypnea: acidosis, shock, anxiety
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- CT chest if unsure of underlying etiology
-- Trend ABG/VBG, lactate
-- Daily CXR
-- Vent Settings: Vt: *** RR *** PEEP *** FiO2 ***; change *** to ***
-- Sedation: RASS goal *** ; *** (propofol, dexmedetomidine/precedex, midazolam; refractory agitation - quetiapine, haldol )
-- Analgesia: *** (fentanyl 25-50mcg bolus, 50-200/h; dilaudid, morphine)
-- Volume: ***
-- Barriers for Extubation: *** (tx etiology, P:F>150, PEEP <=5, FiO2 <=0.4, pH>7.25, can cough, secretions, HD stable off pressors, ideally alert, follow commands)
-- SAT/SBT *** (30-120 min SBT trials daily with PEEP <=5 - increase timing)
-- Secretions: *** (nebs, acetylcysteine/mucomyst, glycopyrrolate, steroids)
-- If expected intubation >14 days, discuss tracheostomy
The patient remains intubated due to *** (ARDS, PNA, COPD, AMS, etc)
They have the following vent settings: *** (Mode / Tidal Volume / RR / PEEP / FiO2)
On these settings, the ABG is *** (pH / pCO2 / paO2 / sat)
The patient's oxygenation is *** (improving / worsening) and the CXR is *** (better / worse)
To improve oxygenation I propose we *** (diurese, FiO2, PEEP, etc)
To improve ventilation I propose we *** (RR, Vt, prone, etc)
We should continue *** to treat ***
We should send/follow up *** to further work up the etiology of respiratory failure.
We are *** ready for spontaneous breathing trial today; limiting factors may include *** (oxygenation, ventilation, neuro status, airway).
Current sedation is ***.
We are *** at goal OR should make the following changes ***.
PDF coming soon!
If a patient is showing evidence of respiratory failure, do not wait to intubate. Start with AC/VC with lung-protective settings until you understand the etiology. Start with propofol and precedex for sedation and fentanyl for analgesia. Oxygenatin is driven by FiO2 and PEEP; ventilation is driven by RR and tidal volume (Vt). High peak pressure but low pplat suggests increased airway resistance; high peak and high pplat suggest low lung complicnace. Auto-PEEP is incomplete alveolar emptying - decrease RR to decrease I:E ratio. The requirements for extubation include: addressing the etiology of respiratory failure, managing O2 and CO2 (PEEP <=5, FiO2 <=0.4, pH >7.25), cough intact, secretions manageable, HD stable, ideally alert and following commands. Perform SBTs daily - causes of failure include ongoing underyling process, overload, weakness, delirium, anxiety, metabolic causes.